SPECIAL COMMUNICATION
School Refusal and Psychiatric Disorders: A Community Study

https://doi.org/10.1097/01.CHI.0000046865.56865.79Get rights and content

ABSTRACT

Objective

To examine the association between anxious school refusal and truancy and psychiatric disorders in a community sample of children and adolescents using a descriptive rather than etiological definition of school refusal.

Method

Data from eight annual waves of structured psychiatric interviews with 9-to 16-year-olds and their parents from the Great Smoky Mountains Study were analyzed.

Results

Pure anxious school refusal was associated with depression (odds ratio [OR] = 13, 95% confidence interval [CI] 3.4, 42) and separation anxiety disorder (OR = 8.7, 95% CI 4.1, 19). Pure truancy was associated with oppositional defiant disorder (OR = 2.2, 95% CI 1.2, 4.2), conduct disorder (OR = 7.4, 95% CI 3.9, 14), and depression (OR = 2.6, 95% CI 1.2, 56). Of mixed school refusers (children with both anxious school refusal and truancy), 88.2% had a psychiatric disorder. They had increased rates of both emotional and behavior disorders. Specific fears, sleep difficulties, somatic complaints, difficulties in peer relationships, and adverse psychosocial variables had different associations with the three types of school refusal.

Conclusions

Anxious school refusal and truancy are distinct but not mutually exclusive and are significantly associated with psychopathology, as well as adverse experiences at home and school. Implications of these findings for assessment, identification, and intervention for school refusal are discussed. J. Am. Acad. Child Adolesc. Psychiatry, 2003, 42(7):797-807.

Section snippets

Sample

The Great Smoky Mountains Study (GSMS) is an ongoing, longitudinal study of the development of psychiatric disorders in youths living in North Carolina. Full details of the study design can be found elsewhere (Costello et al., 1996).

Briefly, a representative sample of 4,500 children aged 9, 11, and 13 years, recruited through the Student Information Management System of the public school systems of 11 counties in western North Carolina, was selected using a household equal probability design. A

Prevalence

The 3-month prevalence of overall anxious school refusal was 2.0% (n = 165) and of truancy was 6.2% (n = 517). Anxious school refusers were 6.8 times more likely than children without anxious school refusal to be truant (OR = 6.8, 95% CI 3.1, 15; p < .0001). A quarter of anxious school refusers and 8.1% of truants were mixed school refusers (0.5% prevalence; n = 35). Table 1 describes the prevalence, gender, and age characteristics and frequency of the three subtypes of school refusal.

Psychopathology

Table 2

DISCUSSION

The prevalence, age, and gender characteristics of anxious school refusal and truancy were consistent with previous studies (Granell de Aldaz et al., 1984; King and Bernstein, 2001; Stickney and Miltenberger, 1998). Use of “agnostic” definitions of school refusal based on descriptions of the behavior rather than assumptions about etiology or associated psychopathology led to three main findings: (1) All three types of school refusal were significantly associated with psychiatric disorders. (2)

REFERENCES (52)

  • CG Last et al.

    School refusal in anxiety-disordered children and adolescents

    J Am Acad Child Adolesc Psychiatry

    (1990)
  • S Agras

    The relationship of school phobia to childhood depression

    J Psychiatry

    (1959)
  • American Psychiatric Association

    Diagnostic and Statistical Manual of Mental Disorders

    (1994)
  • A Angold et al.

    A test-retest reliability study of child-reported psychiatric symptoms and diagnoses using the Child and Adolescent Psychiatric Assessment (CAPA-C)

    Psychol Med

    (1995)
  • A Angold et al.

    Comorbidity

    J Child Psychol Psychiatry

    (1999)
  • A Angold et al.

    Precision, reliability and accuracy in the dating of symptom onsets in child and adolescent psychopathology

    J Child Psychol Psychiatry

    (1996)
  • A Angold et al.

    The Child and Adolescent Psychiatric Assessment (CAPA)

    Psychol Med

    (1995)
  • I Berg

    Absence from school and mental health

    Br J Psychiatry

    (1992)
  • I Berg et al.

    DSM-III-R Disorders, social factors and management of school attendance problems in the normal population

    J Child Psychol Psychiatry

    (1993)
  • I Berg et al.

    School phobia: its classification and relationship to dependency

    J Child Psychol Psychiatry

    (1969)
  • NR Blagg et al.

    The behavioural treatment of school refusal: a comparative study

    Behav Res Ther

    (1998)
  • C Bools et al.

    The identification of psychiatric disorders in children who fail to attend school: a cluster analysis of a nonclinical population

    Psychol Med

    (1990)
  • IT Broadwin

    A contribution to the study of truancy

    Am J Orthopsychiatry

    (1932)
  • M Cooper

    School refusal

    Educ Res

    (1966)
  • M Cooper

    A model of persistent absenteeism

    Educ Res

    (1986)
  • EJ Costello et al.

    The Great Smoky Mountains Study of Youth: goals, designs, methods, and the prevalence of DSM-III-R disorders

    Arch Gen Psychiatry

    (1996)
  • Cited by (379)

    • Anxiety level and school refusal in anxiety disorders in teenagers

      2023, Neuropsychiatrie de l'Enfance et de l'Adolescence
    View all citing articles on Scopus

    This project was supported by NIMH grants MH-02016 and MH-48085. Dr. Egger receives support from an NIMH Career Development Award (5K23-MH-02016) and a NARSAD Young Investigator Award. The authors acknowledge the assistance of Jane Duncan in the preparation of this paper.

    View full text